New Trend Putting Rest to Bed for Ankle and Other Sport Injuries.
Written by Pat Stanziano, MPT, Hons BSc Kin
Certified McKenzie MDT Provider (MICanada)
Diploma Sport Physiotherapy (Canada)
Registered Int’l Sport Physical Therapist (IFSPT)
Certified Strength and Conditioning Specialist (NSCA)
Lateral ankle sprains (LAS) are a regular occurring musculoskeletal injury commonly found in the general population and those individuals who participate in sports. In fact, about 40% of all LAS occur during sports. That being said, only half of all ankle LASers seek medical attention which increases their risk of developing chronic ankle instability. Despite the numerous studies published on adequate diagnosis, long term effects, treatment and prevention, diversity on this topic persists. Here are recommendations for best practice, as per the recent consensus statement published in the British Journal of Sports Medicine (Gwendolyn, V et al, Mar 2018):
- Modifiable risk factors such as deficiencies in range of motion (ROM), strength, and proprioception should be identified and if possible included in a prevention and/or rehabilitation programme to reduce the risk for recurrent sprains.
- Consideration of the sport and position played lend to options for cross training cross during an injury, and eventually to preventative strength and conditioning programs that reduce the risk of future ankle sprains.
An athlete’s response to pain, their workload, and level of sports participation help formulate a safe return-to-play program.
In cases of a suspected fracture, the Ottawa Ankle Rules should be applied to rule in/out need for diagnostic X-Ray.
- There is no evidence that rest, ice, compression, elevation (RICE) alone, or cryotherapy, or compression therapy alone has any positive influence on pain, swelling or patient function.
- Non-steroidal, anti-inflammatory drugs (NSAIDs) may be used by athletes who have sustained a LAS for the primary purpose of reducing pain and swelling. However, care should be taken in NSAID usage as it is associated with complications and may suppress or delay the natural healing process.
- Ankle bracing, although not necessary, can be recommended for approximately 4–6 weeks. It is preferred over immobilization (casting) because it allows the patient to load the damaged tissue in a protected manner.
- Exercise therapy programs that are initiated immediately after LAS have established efficacy to optimise recovery of joint functionality. It is the most integral component of any treatment administered, and it is associated with quicker time to recovery, enhanced outcomes, and reduces the prevalence of recurrent injuries.
- In combination with exercise therapy, manual joint mobilization directed at improving ankle dorsiflexion enhances the efficacy of manual therapy.
- Surgery is reserved for patients who have chronic instability after a LAS and who have not responded to a comprehensive exercise-based physiotherapy programme.
- Functional Support – Both taping and bracing have a role in the prevention of recurrent LAS despite limited evidence on mechanisms that lead to these beneficial effects.
- Exercise Therapy – It is advised to start exercise therapy, especially in athletes, as soon as possible after the initial sprain to prevent recurrent LAS. Exercise therapy, in the form of proprioception, balance, and coordination, should be included into regular training activities as much as possible..
These guidelines bring to light that use of passive techniques and modalities in the management of musculoskeletal injuries brings little-to-no value to an athlete’s recovery. Dr. Jennifer Robinson, sport medicine physician in the Faculty of Medicine at the University of British Columbia, along with other sport medicine experts think it’s time to retire RICE from the health-care vocabulary (http://thischangedmypractice.com/move-an-injury-not-rice/). Instead, the sport medicine community needs to promote a more evidence-based approach by using the acronym, MOVE:
|M||Movement, not rest, starting with gentle range of motion exercises in unloaded or loaded positions, depending on pain response; and progressing to functional activities.|
|O||Options for cross training that involve exercises for structures not necessarily involved with the injury, but geared toward improving overall performance.|
|V||Vary rehabilitation with strength, balance, and agility exercises, and progressing them accordingly|
|E||Ease back to early activity starting with sport-specific movements and manipulating performance parameters to progress the athlete back to practice and eventually competition.|
A more active and functional rehabilitative approach to injury (excluding fractures and more catastrophic injuries) align well with with principles demonstrating that mechanical loading stimulates structural change. The difficulty lies in finding the optimal dose of loading vs. protection of the injured site (the proverbial ‘sweet spot’). When overloaded, vulnerable tissues can become further damaged. When not loaded enough, no positive adaptations will occur resulting in chronic pain, weakness, or instability. Furthermore injuries vary, so there is no one-size-fits all strategy. That’s why it is important to find a sport medicine professional that will thoroughly assess, diagnose, and devise a program of care routed in therapeutic exercise. But he or she must be able to make modifications on the fly, to get an athlete back to competition in a safe and time-efficient manner.